During inspection of a 52-year-old patient, the nurse notes the abdomen is bulging and stretched with dullness percussed to the left lower quadrant. Which documentation will the nurse complete?
Has a hernia and awaiting surgery.
Has a protuberant abdomen, which requires further investigation.
The person is obese and on a weight loss program.
Has a scaphoid abdomen and there are no concerns.
The Correct Answer is B
A. Has a hernia and awaiting surgery: A hernia presents as a localized bulge that may be reducible and is often accentuated with coughing or straining. A generally bulging, stretched abdomen with dullness on percussion does not specifically indicate a hernia.
B. Has a protuberant abdomen, which requires further investigation: A protuberant abdomen refers to one that is distended or bulging outward, which fits the findings of stretching and bulging. Dullness on percussion suggests the presence of fluid or mass, meaning further diagnostic evaluation is warranted.
C. The person is obese and on a weight loss program: Obesity can cause a rounded abdomen, but percussion would reveal more tympany than dullness. The clinical note of dullness in the lower quadrant suggests something other than simple obesity, such as ascites or mass.
D. Has a scaphoid abdomen and there are no concerns: A scaphoid abdomen is sunken inward, the opposite of bulging or protuberant. This description does not match the nurse’s findings of a stretched, outwardly bulging abdomen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Probable signs of pregnancy: These include objective findings observed by the examiner such as a positive pregnancy test, Hegar’s sign, or an enlarged uterus, not subjective symptoms like nausea and amenorrhea.
B. Positive signs of pregnancy: These are definitive signs such as visualization of the fetus on ultrasound, detection of fetal heart tones, or palpation of fetal movement by the examiner. The client’s symptoms do not confirm pregnancy.
C. Possible signs of pregnancy: This term is not typically used in obstetric classification. The recognized categories are presumptive, probable, and positive signs of pregnancy.
D. Presumptive signs of pregnancy: Subjective symptoms reported by the woman such as nausea, breast tenderness, fatigue, and amenorrhea fall under presumptive signs, since they could also be caused by other conditions.
Correct Answer is B
Explanation
A. Shiny, pink tympanic membrane: A normal tympanic membrane is typically pearly gray in color, not shiny pink. A pink appearance could suggest inflammation or infection, which would not be considered normal in an older adult.
B. High-tone frequency loss: Presbycusis, the age-related hearing loss, usually begins with difficulty hearing high-frequency sounds such as consonants. This is a common and expected finding in older adults and is considered a normal age-related change.
C. Increased elasticity of the pinna: With aging, the pinna tends to lose elasticity and become more rigid rather than more flexible. Increased elasticity is not characteristic of older adults and would not be considered normal.
D. Thin, translucent membrane: Aging tympanic membranes often become thicker and more opaque, not thinner and translucent. Increased opacity is a typical age-related finding and helps distinguish older tympanic membranes from those of younger adults.
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